Tuesday, October 18, 2011

Bucking the Established

"Out with the old, in with the new!"

Who's your doctor? Do you have one?

If you have one, you aren't that interesting to them any longer because you're "established." This is not the fault of your doctor, but because of government rules for paying doctors: "new patient" visits pay better than "established patient" visits. "New patients" have a much better chance of needing new procedures, so they are even more special. Add to that the fact that more and more patients are going to need to become part of the "system" soon, and "new patients" quickly achieve the health care value trifecta.

Sorry. Those are the rules.

The higher payments made by insurers and government agencies for new patients was meant to offset the longer amount of time and cognitive challenges of dealing with a new patient that enters the doctors office. There is no question that there is more work to do when a new patient enters a medical facility: entering demographic data on a computer, actually taking a set of vital signs, performing a careful history and physical. But thanks to the explosion of ancillary health care assistants, imaging studies, the availability of the internet, and a constant push to do more in less time, doctors work differently today than they once did. Much of the data gathering is accomplished before the patient enters the office, imaging studies and baseline testing often occurs before a patient is even seen (remember those tests "required" for "quality" care?). Furthermore, because limitations for the frequency of testing has been imposed by government regulators, health care systems leap at the opportunity to "direct" doctors to order tests the moment the test might be needed. As such, "new patients" become particularly valuable to health care systems compared to "established" ones.

But are established patients really that tarnished? Should a doctor's time with them be valued any less than the time spent with a new patient? Is there value in that continuity of care? Or are we just creating a incentivized human funnel to our health care system that favors new patients over those with whom we might develop relationships? Is the doctor-patient relationship at risk as a result?

5 comments:

Our family has been going to the same Urgent care facility for many years. We do not go often but when we do, it is always to the same one, run by the same group and we often end up seeing the same physician. Despite this, each time we go, we are billed for a "new patient" registration fee (I think $40-$50). This is because they claim that, as they are an Urgent Care Facility, they do not keep records. Which I am sure is NOT true.The extra fee for new patients already exists and was implemented by the hospitals & clinics a long time ago.

If it's more than 3 years between visits for a given patient, it is considered a new visit. If you get treated for a urinary tract infection, and the urgent clinic doctor wants to see you back in a week to see if their treatment has been effective, that shouldn't be a "new patient" visit. Even hospital ERs are required to keep records for seven years, just like doctor's offices

A nice article about the arrogance of thinking that a committee (or many) can review medicine and determine what fees are appropriate for what services. It's not a funny matter. Prices determine where resources go or don't go, and prevent efficient reorganization of services.

It is an old mistake of central planning and Marxist economics, that the value of a service is equal to the labor used to deliver it. This perpetuates a system where you must do more labor to get paid, rather than deliver a more valuable and efficient service. Email no pay, phone consult no pay, office visit yes pay.

In 1978 and 1979 airlines and trucking were deregulated. The FCC and ICC had thousands of rules about who could start an airline or trucking firm, and exactly what had to be charged for each type of passenger, route, commodity, and situation. All of this was to promote fairness and efficiency.

The inefficiency, uncertainty, and complexity were rapidly raising the costs of transportation. After a period of trying to fix things with even more nuanced regulation, the industries pressured Congress to give up. Everything became cheaper and better when the hand of government planning was lightened.

Why is this lesson forgotten each time regulation begins to raise the costs of regulated industries?

Andrew_M_Garland said..."... the arrogance of thinking that a committee (or many) can review medicine and determine what fees are appropriate for what services."What outstanding ideas! It's amazing how the progressives can weasel in that type of central planning into our laws, and most Americans never notice!Thanks for the link!

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About Me

Westby G. Fisher, MD, FACC is a board certified internist, cardiologist, and cardiac electrophysiologist (doctor specializing in heart rhythm disorders) practicing at NorthShore University HealthSystem in Evanston, IL, USA and is a Clinical Associate Professor of Medicine at University of Chicago's Pritzker School of Medicine. He entered the blog-o-sphere in November, 2005.
DISCLAIMER: The opinions expressed in this blog are strictly the those of the author(s) and should not be construed as the opinion(s) or policy(ies) of NorthShore University HealthSystem, nor recommendations for your care or anyone else's. Please seek professional guidance instead.